Clearing the air

Quality-focused long-term care providers take infection prevention extremely seriously and go to lengths to ensure that hand washing and cleaning of environmental surfaces are a top priority.

Unfortunately, the same kind of attention isn't always given to air quality, even though the air we breathe can be a direct vehicle for health-deteriorating pathogens, microbes and other potentially dangerous particulates and contaminants — some of which can remain in the lungs for years or even migrate into the bloodstream.

Indeed, indoor air quality's impact on health is significant. Indoor air is two to 10 times more polluted than outdoor air, and it can be as much as 1,000 times more polluted when construction or renovations are underway, according to the U.S. Environmental Protection Agency. What's more, at least 16% of hospital-acquired infections are airborne in origin, noted Tom Petersen, an environmental engineer who serves as president of Environmental & Engineering Solutions Inc.

“Common diseases in health facilities caused by airborne bacteria and molds include pneumonia, surgical site infections and contagious respiratory infections, such as tuberculosis and influenza. In addition, some urinary tract infections and even blood infections may result from airborne particles settling on equipment,” he said.

Despite those risks, indoor air quality's impact on resident and staff health and wellness continues to be underestimated in many facilities.

“I don't feel that indoor air quality gets the attention it [deserves] until a severe problem occurs and health is compromised,” said Tony Abate, vice president of operations for AtmosAir Solutions. Contributing to the long-term care environment's shortcomings in addressing air quality are the facts that poor air quality cannot be seen and most mild symptoms are mistakenly attributed to compromised health associated with old age, he added.

Maintain the system
Because older residents are more susceptible to illness, including chronic respiratory complications, allergies, asthma and infection, and because residents spend the vast majority of their time indoors, experts agree that operators must become more proactive. They must address indoor air quality and take measures to limit exposure to all forms of airborne contaminants — whether they're mold, dust and pollen to bacteria, viruses, gases, volatile organic compounds and more.

Ensuring good indoor air quality (IAQ) takes a multi-pronged approach, one that begins with a comprehensive profile to determine the current air quality and identify existing operational and maintenance practices.

“The IAQ profile should then be used to determine any conditions or practices that should be improved,” Petersen explained.

Having an IAQ manager who is familiar with the facility and all air quality procedures is another critical element, Abate added.

The EPA defines three key elements in promoting good indoor air quality: source control, ventilation and air cleaning.

Proper ventilation, operation and professional maintenance of heating, ventilation and air conditioning (HVAC) systems are critical for delivering necessary airflow to address airborne contaminants — and they're elements that are often overlooked, Abate said.

“Air ducts can become quite contaminated over time and should be inspected and cleaned every two to five years,” he said.

HVAC system and conditioning coils should be cleaned to remove build-up and contamination. High-efficiency filtration (MERV 13-16 filters) also should be used for HVAC systems that can accommodate them.

“Active strategies, such as bipolar ionization should also be used to address contaminants within the occupied spaces, and passive strategies, such as ultraviolet light systems used at HVAC system conditioning coils to prevent build-up of molds and bacteria,” Abate explained.

The key to proper HVAC cleaning lies in contracting with the right professionals.

“Maintaining a commercial HVAC system is a highly technical job that involves cleaning with a HEPA vacuum, and pulling [certain components out] and power washing them,” said Dayn Benson, director of operations for DUCTZ, an air duct cleaning and HVAC restoration company. “This is not something that just anyone can do. It should only be done by certified, qualified and trained professionals.”

Thorough system cleaning and maintenance can extend HVAC equipment life and lower utility bills by 30%, he said.

Petersen said service providers should use HEPA filtration on all cleaning equipment. They should supply respirators for workers and occupants, and, ideally, vacate the premises during cleaning.

That's not to say facility maintenance and environmental services staff members don't play an important role.
At Sanctuary at Holy Cross in Burtonsville, MD, the maintenance manager walks with the contracted service vendor during quarterly reviews to ensure compliance for duct cleaning and filter replacements.

“It also affords us the earliest opportunity to identify concerns prior to any health risk to [residents] and staff,” said Director of Nursing Ella Willard, RN. Maintenance staff also complete quarterly audits of resident rooms to ensure that filters are replaced and everything is in good working order. Environmental services staff routinely clean all vents.

“We also use cleaning products with a low odor and a high cleaning impact. Our staff ensure that the products we use not only remove germs and dust, but also prohibit the growth of any potential for mold,” she continued.

While routine vent cleaning is beneficial and can be performed by in-house staff, Benson warned that significant build-up on vents may indicate a bigger problem that warrants professional help.

“This is usually a sign of a system being out of balance,” he reasoned, stressing that air balancing is a must for ensuring adequate airflow to all areas.

Target the source
Excessive condensation is another common culprit of poor system function and, often, mold proliferation. Facilities in warm climates where air conditioning is routinely used are particularly vulnerable to “wet growth,” Benson said. Therefore, vents should be routinely checked for build-up.

Moisture isn't just a problem for HVAC systems, either. Any signs of water infiltration can spell trouble for indoor air quality.

One significant shortcoming is the slow response to water infiltration, according to Petersen.

“Leaky roofs, pipes, HVAC systems or other water sources should be promptly addressed,” he emphasized. “Any standing water or wet building materials, such as ceiling tiles, should be an immediate tip-off that there is a water infiltration problem. The wet areas should be dried as quickly as possible and the source of water should be identified and fixed so that mold growth will be inhibited.”

Proper ventilation is another must, particularly in areas that can become moist and steamy, such as kitchens and bathrooms.

If mold is observed, smelled or suspected, Petersen urges facilities to hire a professional to take air samples, wipe samples and/or bulk samples and determine the variety and amount of mold present in the suspected area. “If levels are high, a mold remediation specialist should be consulted to determine appropriate measures to decrease levels,” he added.

Sanctuary at Holy Cross focuses on both internal and external environments, inspecting vents, roof fans and attic spaces, and keeping them debris-free.

“We also make sure our pipes are in good working order, which helps prevent the risk of mold and mildew spores [entering] the air,” said facility maintenance manager Brian McAllister.

Controlling the relative humidity throughout the facility to between 30% and 60% also will go a long way toward preventing or minimizing biological growth and airborne contaminants, Petersen added.

Dehumidifiers may be necessary to keep humidity in a healthy, manageable range.

Some of the biggest sources of poor indoor air quality are less obvious and, thus, often overlooked. Items such as carpeting, drapes and mattresses, in particular, require focused attention because they can be a breeding ground for airborne contaminants, sources explained.

While Benson revealed that carpet is better for air quality than hard flooring surfaces because it captures a significant amount of particulates, it also can house and release microbiological contaminants if not properly cleaned.

Daily vacuuming — with a high-quality, HEPA vacuum — is a must, and high-traffic carpeted areas should be cleaned using hot water extraction at least every three to six months, he said.

“Drapes are an issue because they are often never cleaned, even though they catch a lot of dust and particulates that can degrade air quality. The same goes for couches and other upholstered furniture. Mattresses also release particulates, especially when bedding is changed, so they should be routinely vacuumed,” Benson added.

And don't underestimate the value of good old-fashioned hand washing and adherence to appropriate contact precaution when working to improve indoor air quality, experts emphasized.

Sanctuary at Holy Cross makes hand sanitizer fluid readily available and routinely reminds everyone that nothing replaces the value of soap and warm water hand washing.

“Many viruses are exchanged via airborne contamination, which is why we take care to clean thoroughly and often. This is especially true in community areas that are used by multiple individuals,” Willard explained. “Microbial cleaning products with low-fume emissions are of extreme importance. The areas of greatest concern are not the ones commonly considered, such as bathrooms, but the surfaces we all touch — the light switches, the door handles, and so on.”

In addition to opting for non-toxic cleaning products wherever possible, sources also stressed the importance of diligently following manufacturer instructions for use. They emphasized that the notion “If a little is good, a lot must be better” is a dangerous one, especially in the seniors housing environment.

Residents already suffer from weakened immune systems and diminished organ function, and are more vulnerable to indoor air pollution.

Building for success
If a renovation is underway or new construction is in the works, “completely seal the parts of a building undergoing renovation,” urges Mara Baum, AIA, LEEP AP BD&C, senior associate and healthcare sustainable design leader for global architectural firm HOK Healthcare. “Limit the locations where construction workers move through occupied spaces to renovation sites, and provide space for them to clean their shoes and clothing before entering clean rooms.”

Maintaining negative air pressure within the construction zone also is prudent, as are covering return air vents in the space and enhancing filtration and filter changes on affected HVAC systems, added Abate.

“Also, IAQ testing should be performed during and post-construction to ensure no problems have arisen as a result of construction,” he noted.

Another wise move: waiting to install soft materials such as curtains and fabric furnishings until after paints, coatings, adhesives, sealants, flooring, ceiling tiles, insulation, composite wood or other products have had a chance to fully dry and off-gas.

“Soft materials will soak up contaminants and rerelease them over time,” Baum warned.

The bottom line, sources agreed, is that a facility has a responsibility to maintain good indoor air quality each and every day, regardless of the circumstances and challenges.

“What you can't see can hurt you,” Abate said. “Addressing indoor air quality on a regular basis will help prevent air quality problems and associated health problems, and provide a cleaner, healthier facility for [residents], staff and visitors.”